A lung transplant patient died after receiving SARS-CoV-2-infected lungs from a donor with a negative nasopharyngeal test, according to a U.S. case report. The donor had no clinical history indicating exposure to the virus, along with a negative PCR test within 48 hours of procurement. The recipient, who also had a negative upper respiratory PCR test just 12 hours before the transplant, began to decline within two days after the surgery. By three days post-transplant, the patient developed worsening fever, hypotension and ventilator requirements, according to the report in the American Journal of Transplantation. When a CT scan showed multifocal consolidations in the patient's lungs, her doctors began to fear the donor had an undetected SARS-CoV-2 infection. They collected a bronchoalveolar lavage (BAL) from the recipient and tested the sample for the virus. When it turned out to be positive, they tested a BAL that had been collected from the donor lungs prior to transplant; it, too, was positive for the virus. The donor, a car-crash victim who progressed to brain death during a two-day hospitalization, had undergone a chest CT scan on the day of admission that showed areas of consolidation within the posterior right lower lobe, according to the case report. The radiologist interpretation at the time was that these areas represented atelectasis and pulmonary contusion. The donor lungs were not tested for SARS-CoV-2 prior to transplant. "In my view, all potential lung transplant donors should have a specimen collected from deep within the lungs in addition to the standard nasopharyngeal swab to be tested for SARS-CoV-2," said lead author Dr. Daniel Kaul, director of the transplant infectious disease service at the University of Michigan, Ann Arbor. "This would clearly provide an added layer of safety." It's not possible to say how many SARS-CoV-2 infections are being missed, Dr. Kaul said, adding, "but this shows they can be missed, with severe consequences." Doctors recognized something was wrong soon after the surgery. "It became apparent quickly that something was going wrong after the transplant because the surgery went fine and she was doing fine in the first post-operative day," Dr. Kaul said. "Then she developed pneumonia, a fever and low blood pressure and she didn't respond to antibiotics." Since Dr. Paul's institution regularly collects a BAL from the donor lungs to test for ureaplasma, they had a sample to test for SARS-CoV-2. By this time, the transplant surgeon had also gotten sick and tested positive for the virus. The surgeon, it turns out, had worn only a surgical mask when preparing the lungs for transplant because both donor and recipient had tested negative for SARS-CoV-2. "He may have had the most direct exposure," Dr. Kaul said. "We may have gotten lucky in that only one person became infected," he noted. "We are now very concerned about using lungs that haven't been tested," Dr. Kaul said. "We think everyone doing lung transplants needs to think about that. That's why we decided to publish. We think this needs to be out there and considered in the transplant community and hopefully encourage all of us to get involved in overcoming barriers to testing lower respiratory tract specimens and getting tests back quickly." Dr. Ghady Haidar, a transplant infectious disease physician at UPMC in Pittsburgh, said he's been discussing this case with his colleagues. "I think it was inevitable that something like this was going to happen," Dr. Haidar said. "Donor derived infections are terrible when they happen. They're uncommon but expected." In hindsight, testing the BAL fluid would have avoided all of this, Dr. Haidar said. "It makes me wonder whether organ procurement organizations and transplant centers will be more strict about making sure there is always a BAL sample from thoracic organ donors before transplants happen." "All you need is one case like this to happen to make people rethink how they are approaching things," Dr. Haidar said. "I think the other thing that needs to be discussed is the surgeon who was infected. We really, really need to do our best to preserve our healthcare workforce. Our advice is for lung transplant surgeons to wear full PPE regardless of test results because of the possibility of a false negative test." —Linda Carroll Source
